Laying groundwork for a heart transplant

By Jeremy Lim, Published TODAY, 13 Mar 2013

If Health Minister Gan Kim Yong was a cardiac surgeon and the healthcare financing system a patient with heart failure, yesterday’s Committee of Supply budget announcements would be a “bridge to transplant” — necessary measures to keep the patient alive and with the latest devices, even walking about with reasonable function.

The definitive treatment would be a heart transplant, a new heart free of the diseases that plagued the old one and prevented living life to the fullest.

Mr Gan announced substantial financing initiatives but conceded that these were temporary salves while he and his officers worked on a major review of the system.

Saying in Parliament yesterday “The review of our healthcare financing system will be extensive, and will involve fundamental shifts”, the health minister asked for time to carefully study the changes needed.

He urged caution and patience because as he put it, “If we get it wrong, we leave a heavy burden of debt for our children and grandchildren”.

POTENTIALLY TRANSFORMATIVE CHANGES

Many of the initiatives are a welcome start. The Minister has acknowledged the concerns of the man on the street and is courageously following through on the pledge he made that no Singaporean will be denied healthcare because he cannot afford it.

Many of the temporalising measures are incremental — more beds, more hospitals, more doctors and nurses — but some changes hinted at are potentially transformative.

Shifting funding from the acute hospitals to other parts of the healthcare system, especially primary and extended care, will encourage transformation. Liberalising Medisave usage to extend beyond hospitals, expanding MediShield to include even more outpatient services, will facilitate the development of the healthcare system in a more balanced manner.

Currently, the somewhat unbalanced growth, with muscular hospitals and anaemic “everything else”, is a result of the emphasis on acute hospitals all these years; shifting the flows of financials can effect profound transformation of primary care as well as the intermediate and long-term care sectors.

Will it work? We don’t know. Will it help? Most definitely.

Professor Steven Landsberg, author of the popular The Armchair Economist, has baldly stated: “People respond to incentives. The rest is commentary.”

DON’T SETTLE FOR STOP-GAP

The announcements yesterday are encouraging. Even more encouraging is the recognition that more infrastructure, a much larger healthcare workforce and much more funding are necessary but insufficient.

Nonetheless, there is cause for concern. The healthcare challenges facing us today are a crisis in slow motion. There is a real danger we will lose momentum and be satisfied with stop-gap measures, falsely believing they will suffice.

The heart surgeon may be happy after a successful implantation of a device as a “bridge to transplant” for a failing heart, but he does not let up on finding a suitable heart for transplant.

“With an ageing population, rising labour costs and the use of expensive technology in modern medicine, further increases in healthcare expenditure are to be expected … There is therefore an urgent need to seek out and use cost-effective approaches to healthcare.”

These words could have been spoken in the hallowed chambers of Parliament yesterday, but they were actually written in 1991 by then Minister of State for Health Dr Aline Wong, on behalf of the Review Committee on National Health Policies.

Did we drop the ball? I do not think so, but it is clear that we did not as a country prioritise the ageing population with the urgency it deserved.

There is an interesting parallel with defence. No one questions whether defence is financially sustainable. Defence is “existential” and it is a given Singapore will do whatever it takes to have a strong effective defence force.

If the health and wellbeing of Singaporeans were equally existential, would we be framing the issues differently and with a different tempo?

A civil servant commented to me recently: “The current narrative is still heavily weighed on the economics ‘existential threat’ … But we do not sufficiently ask if we may be the ones with the systemic blindside, that perhaps it is the Government that has not understood the people’s ‘irrational’ concerns and has downplayed the social realities.

“The intent is not to automatically conclude that we must sacrifice economic growth, but if we began to treat social issues as ‘existential’ and put as much energy in finding creative solutions, we may come up with a very different set of new possibilities, more than the current almost black-and-white scenarios painted.”

One final observation. Dr Wong’s 1991 report was low on financials and high on outcomes, setting targets like “to reduce the overall obesity level in the population to 3 per cent” and “to increase the proportion of Singaporeans who exercise regularly to 40 per cent by the year 2000”.

Yesterday’s speeches were high on dollars, beds and hospitals, but short on targets. I hope in the review to follow, the Government will focus its efforts not just on outputs, but also on outcomes.

Only by doing so, and emphasising outcomes that put the Singaporean at the centre, will we truly know whether our healthcare transformation has been successful.

Only one ‘right’ question to ask
By Jeremy Lim, Published TODAY, 20 Mar 2013

A fundamental review of Singapore’s healthcare financing system is underway. In last week’s Committee of Supply debates, Health Minister Gan Kim Yong declared: “The review of our healthcare financing system will be extensive, and will involve fundamental shifts.”

He also announced that the Government will “take on a greater share of national spending, from the current one third to about 40 per cent and possibly even further”.

During the ensuing debates, there were calls to allow Medisave usage for screening and certain disease treatments, to increase coverage of MediShield and enable more Singaporeans to tap on Medifund.

Are these “fundamental shifts”?

I teach strategy in the local universities and one key insight is that in deciding strategies, always go back to an organisation’s mission and vision. If in doubt, “true north” is to be found by taking bearing from one’s mission.

What is the mission of the Health Ministry? It is “Championing a healthy nation with our people — To live well, live long and with peace of mind”. Since the emphasis is on healthcare financing, let’s focus on peace of mind.

Rather than labour over whether to tweak Medisave or expand MediShield, may I humbly suggest asking instead: What will give us peace of mind?

‘FREE’ IS not FREE

“Free healthcare” would be the glib retort, but Singaporeans are responsible enough to know that anything “free” leads to over-consumption and wastage.

In fact, the Singapore Democratic Party’s health plan, cleverly sub-titled Caring for All Singaporeans, calls for co-payments of 10 per cent, albeit with caps of S$2,000 per calendar year. Likewise, the Workers’ Party’s 2011 Manifesto agrees with the need for co-payments.

I think we can safely conclude there is unanimity across the political spectrum that “free healthcare” in the model of the original English National Health Service is not for Singapore.

The critical issue, then, in determining peace of mind is the level of co-payment by citizens — and that should be the rightful starting point for a fundamental review, which must focus on the patient.

To look first at Medisave, MediShield, Medifund and subsidies is akin to the tail wagging the dog. These are second-order questions which follow on after answering the first. Only one question is paramount: What is the appropriate level of co-payment?

This question can be further sharpened by income stratification or type of healthcare to conserve limited funds. Once we have determined what is the appropriate co-payment, the rest of the financing mechanisms can then come into play.

How can the rest of the medical bill be paid for? Whom should the Government subsidise more? Whom less? How much to come from Medisave? How much from MediShield? What about those with limited Medisave dollars? When does Medifund kick in?

30 YEARS A LONG TIME

Some would argue that such an approach would be reckless, putting at risk the country’s finances and everything built up over the last five decades. I would remind them of Thomas Jefferson’s words: “The purpose of government is to enable the people of a nation to live in safety and happiness. Government exists for the interests of the governed, not for the governors.”

I would further add that fears of wanton over-spending are overblown. No one is advocating free healthcare; the calls are for peace of mind and affordable healthcare.

It has been 30 years since Singapore introduced Medisave and the notion of individual responsibility. Interestingly, the British daily The Guardian, in the article “From user fees to universal healthcare — A 30-year journey”, described the Damascene 30-year-long conversion of one David de Ferranti, who in the 1980s was central to the World Bank’s efforts to introduce user fees into healthcare.

In 1985, he had written, “there appears to be considerable scope for having users bear a larger share of healthcare costs”. Fast forward to the present and Mr de Ferranti is the lead author for a prominent Lancet medical journal series (launched together with the Rockefeller Foundation and Results for Development Institute at last year’s United Nations General Assembly) advocating for universal health coverage.

Speaking to The Guardian, he mused: “The world has completely changed. Thirty years. Three decades. That’s a long time. Things change and arguments should change. And in the presence of more resources and the ability not just financially but administratively of countries to manage these programmes, which was again not there 30 years ago, it just now makes eminent sense and I have been outspoken in this — to move towards universal health coverage systems.”

Mr Gan should be applauded for initiating a fundamental review of Singapore’s healthcare financing framework. I hope think-tanks, academics, clinicians, citizens, all support him in asking and answering the right questions.

Jeremy Lim has held senior executive positions in both the public and private healthcare sectors. He is writing a book on the Singapore health system.